Adult Health II: Cardiovascular and Respiratory (NUR 440 B)

The correct answer is: A. It is likely that the client is developing a secondary bacterial pneumonia.

Explanation:

The client initially had flu symptoms such as headache, fever, and chills, which are consistent with a viral infection (influenza). However, the development of a productive cough with yellow sputum and diffuse crackles upon auscultation are concerning signs of a secondary bacterial infection, which is a known complication of the flu. Secondary bacterial pneumonia often follows viral respiratory infections, and the yellow sputum suggests bacterial infection due to the presence of pus. The diffuse crackles heard in the lungs are another indication that fluid or infection may have entered the alveoli, commonly seen in pneumonia.

Why the other options are incorrect:

 The assessment findings are consistent with influenza and are to be expected.

While influenza can cause flu-like symptoms (fever, chills, headache), the productive cough with yellow sputum and the diffuse crackles are not typical symptoms of influenza itself. These findings are more suggestive of bacterial pneumonia, which is a complication of viral infections like the flu.

The client is getting dehydrated and needs to increase her fluid intake to decrease secretions.

Dehydration could contribute to thicker mucus, but it does not explain the yellow sputum and crackles. These signs are much more indicative of infection, not dehydration. It is important to investigate further for potential bacterial pneumonia rather than just increasing fluids.

 The client has not been taking her decongestants and bronchodilators as prescribed.

Although bronchodilators and decongestants are often used to manage respiratory symptoms, this client’s symptoms of yellow sputum and diffuse crackles point to a secondary infection, not poor adherence to medications. These findings suggest an infection rather than an issue with bronchodilator or decongestant use.

Summary:

The client’s flu symptoms have progressed to include a productive cough with yellow sputum and diffuse crackles, which are concerning for a secondary bacterial pneumonia. This complication is common after influenza, especially in elderly individuals. Prompt intervention and possible antibiotic therapy are necessary to treat the bacterial infection.

The correct answer is:  Chronic obstructive bronchitis

Explanation:

The term "blue bloater" is commonly used to describe individuals with chronic obstructive bronchitis, a type of chronic obstructive pulmonary disease (COPD). The term reflects the two main features observed in these patients: cyanosis (the "blue" part) and peripheral edema (the "bloater" part). Cyanosis occurs because chronic bronchitis leads to impaired gas exchange and hypoxia (low oxygen levels in the blood), which gives the skin a bluish tint, particularly around the lips and fingers. Peripheral edema (or bloating) can develop because of the right-sided heart failure (cor pulmonale) that often accompanies chronic bronchitis due to prolonged pulmonary hypertension. Thus, chronic obstructive bronchitis is characterized by chronic cough, sputum production, cyanosis, and edema, all of which are consistent with the "blue bloater" description.

Why the Other Options Are Incorrect:

Adult respiratory distress syndrome (ARDS)

ARDS is an acute condition that results from severe lung injury, often leading to severe hypoxia and respiratory failure. It is not associated with the chronic features (cough, sputum production, cyanosis, edema) seen in blue bloaters. ARDS typically presents with rapid onset of symptoms and is not a long-term, progressive condition like chronic bronchitis.

 Asthma

Asthma is a chronic inflammatory disorder of the airways that leads to wheezing, shortness of breath, and coughing, but it does not typically cause the cyanosis and edema seen in blue bloaters. Asthma is also reversible with treatment, unlike chronic bronchitis, which is progressive and irreversible.

Emphysema

Emphysema is another form of COPD, but it is characterized by alveolar damage and air trapping, leading to dyspnea (difficulty breathing). People with emphysema often appear as "pink puffers" due to shortness of breath and increased effort to breathe, but they generally do not exhibit the cyanosis or peripheral edema seen in "blue bloaters." "Pink puffers" are typically not as cyanotic as "blue bloaters."

Summary:

The term "blue bloater" refers to individuals with chronic obstructive bronchitis, a type of COPD, characterized by cyanosis (blue) and peripheral edema (bloater). These individuals often experience hypoxia and right-sided heart failure. In contrast, conditions like ARDS, asthma, and emphysema do not present with the same clinical features as chronic bronchitis and do not align with the "blue bloater" description.

The correct answer is: "The shunting caused by the PE increases the client's risk for atelectasis."

Explanation:

Pulmonary embolism (PE) is a blockage in one of the pulmonary arteries, usually caused by a blood clot. This blockage can cause various complications, including shunting of blood, which refers to blood flow being diverted away from the alveoli (air sacs in the lungs) where gas exchange takes place. In cases of PE, the shunting of blood to areas of the lung that are not ventilated (due to the embolism) can increase the risk of atelectasis. Atelectasis occurs when a portion of the lung collapses, usually due to a lack of ventilation or obstruction, leading to reduced surface area for gas exchange. In the case of PE, shunting reduces the perfusion of well-ventilated areas of the lung, while poorly ventilated areas (because of the blockage) still receive blood flow, increasing the risk of atelectasis.

Why the other options are incorrect:

"This client is not currently at risk for developing atelectasis.": This statement is incorrect because clients with pulmonary embolism are at risk for atelectasis due to the altered ventilation-perfusion (V/Q) mismatch and shunting caused by the PE, as explained above. A PE disrupts the normal lung function, making atelectasis more likely.

"This client is only at risk for atelectasis if pulmonary hypertension occurs.": While pulmonary hypertension can complicate a PE and potentially lead to right-sided heart failure, atelectasis can occur even without pulmonary hypertension. The shunting and impaired gas exchange from the PE itself can lead to atelectasis, independent of pulmonary hypertension.

"The dead space created by the PE increases the client's risk for atelectasis.": This statement is somewhat misleading. Dead space refers to areas of the lung that are ventilated but not perfused with blood, meaning gas exchange cannot occur in these areas. While dead space is a consequence of PE (as blocked pulmonary arteries create areas of the lung where ventilation cannot match perfusion), it is not directly responsible for atelectasis. The shunting and ventilation-perfusion mismatch due to the embolism are more directly linked to the risk of atelectasis.

Summary:

In clients with pulmonary embolism (PE), the shunting caused by the blockage of blood flow to certain parts of the lung increases the risk for atelectasis. The diversion of blood away from ventilated areas can impair oxygen exchange and promote lung collapse, leading to atelectasis.

The correct answer is: Crackles.

Explanation:

In chronic heart failure, the heart's ability to pump blood efficiently is impaired, leading to fluid accumulation in the lungs (pulmonary congestion) and other parts of the body. The most common abnormal chest sound associated with this fluid buildup is crackles (also known as rales). These are fine, intermittent popping or crackling sounds that are typically heard during inhalation and are a result of fluid in the small airways and alveoli. They are often heard in the lower lung fields and are indicative of pulmonary edema, which is a common complication of heart failure.

Why the other options are incorrect:

Harsh vesicular sounds: Vesicular breath sounds are normal, soft, low-pitched sounds heard over most of the lung fields during quiet breathing. Harsh vesicular sounds are not characteristic of heart failure and may indicate airway obstruction or pathology outside of the lung parenchyma, but not fluid accumulation due to heart failure.

Expiratory wheezes: Wheezes are high-pitched, musical sounds caused by airway narrowing, and they are more commonly heard in conditions such as asthma or chronic obstructive pulmonary disease (COPD). While wheezing can sometimes occur in heart failure, it is not the hallmark sound and is less common than crackles.

Friction rub: A pericardial friction rub is a high-pitched, scratching sound caused by the inflamed pericardial layers rubbing together, typically heard in conditions like pericarditis, not heart failure.

Summary:

In a client with chronic heart failure, the nurse should expect to auscultate crackles, which are caused by fluid accumulation in the lungs due to impaired cardiac function. Other sounds like harsh vesicular sounds, expiratory wheezes, or a friction rub are not typically associated with heart failure.

The correct answer is: Increase FiO2 to 70% and increase PEEP to 8.

Explanation:

ABG Results Analysis:

pH 7.37: This is within the normal range of 7.35-7.45, so the pH is stable and not indicating severe acidosis or alkalosis.

PaO2 40: This is critically low, as normal PaO2 levels range from 75-100 mmHg. A PaO2 of 40 mmHg indicates severe hypoxemia, suggesting inadequate oxygenation.

CO2 45: This is slightly elevated (normal range is 35-45 mmHg), indicating a mild respiratory acidosis due to the inability to eliminate CO2 efficiently.

HCO3 24: This is within the normal range of 22-26 mEq/L, indicating that there has not been significant compensation by the kidneys yet.

Based on these results, the primary issue appears to be severe hypoxemia (low PaO2), and mild respiratory acidosis.

Ventilator Settings:

Assist Control (AC) mode: This mode provides full support, delivering a set tidal volume at a set rate but allows the patient to trigger additional breaths.

FiO2 50%: This is providing 50% oxygen, but given the critically low PaO2, increasing the FiO2 may be necessary.

PEEP 5: PEEP (positive end-expiratory pressure) helps keep alveoli open, but 5 cm H2O may not be sufficient to improve oxygenation in this case.

Why the correct answer is Increase FiO2 to 70% and increase PEEP to 8:

Increase FiO2 to 70%: Given the severe hypoxemia (PaO2 40), increasing the FiO2 will help improve oxygenation.

Increase PEEP to 8: Increasing PEEP helps improve oxygenation by preventing alveolar collapse at the end of exhalation, thus improving gas exchange.

Why the other options are wrong:

A change in the ventilator mode to CPAP: CPAP (Continuous Positive Airway Pressure) is typically used for spontaneously breathing patients to keep the airway open. Since this client is intubated and in respiratory failure, changing to CPAP would not provide the necessary ventilatory support and would likely worsen the situation.

A decrease in tidal volume to 200: Reducing tidal volume would decrease ventilation and could worsen hypercapnia (CO2 retention). This is not an appropriate response to the patient's current ventilator settings, especially when the problem is primarily hypoxemia (low PaO2), not CO2 retention.

Increase the respiratory rate to 18 and adjust FiO2 to 100%: While increasing the FiO2 to 100% might improve oxygenation, simply increasing the respiratory rate is not the primary solution here. The major concern is the severe hypoxemia, and increasing FiO2 to 100% might lead to oxygen toxicity. Therefore, increasing FiO2 to 70% and adjusting PEEP is a more balanced and appropriate intervention.

Summary:

The patient has severe hypoxemia (PaO2 40) and mild respiratory acidosis (CO2 45). The current ventilator settings, although supportive, need adjustments to improve oxygenation. The correct action is to increase FiO2 to 70% and PEEP to 8 to help improve oxygenation while maintaining appropriate ventilation. The other options either address issues that are not as critical or would potentially worsen the patient's condition.

Correct Answer: The kidneys retain bicarbonate.

Rationale:

In respiratory acidosis, the body is experiencing an excess of carbon dioxide (CO₂) due to inadequate ventilation, leading to a drop in pH (acidosis). Since the primary issue is a respiratory dysfunction, the kidneys play a compensatory role by retaining bicarbonate (HCO₃⁻) to help neutralize the acidity and restore acid-base balance. This renal compensation occurs gradually over hours to days and is a key mechanism in chronic respiratory acidosis, such as in COPD patients.

Why the Other Options Are Incorrect

"The lungs will retain carbon dioxide."

This is incorrect because retaining more CO₂ would worsen respiratory acidosis. In COPD, impaired gas exchange already causes CO₂ retention, which is the root cause of acidosis, not a compensatory mechanism.

"The kidneys excrete bicarbonate."

This would be a response to respiratory alkalosis (high pH due to excess CO₂ loss, such as in hyperventilation). Since the patient has respiratory acidosis, the kidneys must retain bicarbonate, not excrete it.

"The lungs will excrete carbon dioxide."

While this is how the lungs normally regulate pH, patients with COPD often have impaired ventilation and are unable to excrete enough CO₂. This is why renal compensation (bicarbonate retention) is the primary mechanism of acid-base balance in these patients.

Summary:

In COPD-related respiratory acidosis, the body compensates by having the kidneys retain bicarbonate (HCO₃⁻) to help neutralize the acid in the blood. This is a slow process and takes days to become fully effective. The other options are incorrect because they either worsen acidosis or describe mechanisms relevant to alkalosis instead of acidosis.

The correct answer is: "Chest physiotherapy helps clear the lungs of secretions."

Explanation:

Chest physiotherapy (CPT) is a therapeutic technique aimed at improving airway clearance by helping to move secretions out of the lungs. It involves a combination of techniques like postural drainage, percussion, and vibration to help loosen and mobilize mucus and secretions, which can then be more easily expelled through coughing or suctioning.

Why the other options are incorrect:

"Chest physiotherapy will help expand the lungs."

 Chest physiotherapy primarily focuses on clearing secretions from the lungs, rather than expanding the lungs. Lung expansion is typically improved through other methods such as deep breathing exercises, incentive spirometry, or positive pressure ventilation techniques.

"Chest physiotherapy helps move the infecting organism out of the lungs."

Chest physiotherapy is designed to clear secretions (which may contain bacteria, viruses, or other microorganisms) from the lungs. While it may help to remove mucus that could harbor pathogens, the primary focus of chest physiotherapy is on mucus clearance rather than directly targeting the infecting organisms. Antibiotics or other treatments are necessary for addressing the infection itself.

"Chest physiotherapy is performed to decrease the amount of coughing."

Chest physiotherapy actually encourages coughing as a mechanism to help expel mucus from the lungs. It does not aim to decrease coughing but instead uses coughing as a vital part of the clearance process. The goal is to make coughing more effective by loosening secretions so that they can be cleared from the airways.

Summary:

Chest physiotherapy helps clear the lungs of secretions by using techniques that promote mucus mobilization and airway clearance, which may help to improve respiratory function in patients with conditions like chronic obstructive pulmonary disease (COPD), cystic fibrosis, or post-operative care. The other options are incorrect because chest physiotherapy does not primarily aim to expand the lungs, remove pathogens, or reduce coughing directly, though it may aid in making coughing more productive.

The correct answer is: Stop the procedure and reoxygenate the client

Explanation:

A decrease in heart rate during suctioning, known as bradycardia, can occur as a result of vagal stimulation, which can happen during the suctioning process. In response to this, the appropriate nursing intervention is to stop the suctioning procedure immediately and reoxygenate the client.

Why this is the correct response:

Bradycardia during suctioning is a potential complication, often linked to vagal stimulation, which occurs when the suction catheter stimulates the vagus nerve, causing a drop in heart rate.

The first priority is to stop the suctioning and reoxygenate the client to correct any hypoxia or oxygen desaturation that may occur during the procedure.

Suctioning should be stopped immediately if any signs of adverse effects, such as bradycardia, are noted. The nurse should then ensure the client is receiving adequate oxygenation to support cardiovascular stability before resuming suctioning if necessary.

Why the other options are incorrect:

 Continue to suction:

Continuing suctioning when a decrease in heart rate is observed could worsen the bradycardia and decrease oxygenation further. It is essential to stop suctioning to assess and manage the client's condition.

Ensure that the suction is limited to 15 seconds:

While limiting the suction time is important, the more pressing issue in this situation is the bradycardia. The priority is to stop suctioning and ensure the client is adequately oxygenated. The 15-second limit applies to suction time but does not address the immediate concern of bradycardia.

Notify the physician immediately:

Notifying the physician is important, but the immediate action is to stop suctioning and reoxygenate the client. Once the client is stable, the physician can be notified, but it is not the first step in this emergency situation.

Summary:

If bradycardia occurs during suctioning, the most appropriate response is to stop the procedure and reoxygenate the client. This ensures that the client’s heart rate stabilizes and oxygen levels are restored before suctioning is resumed. The nurse should focus on oxygenating the client first, then consider any further interventions or notifications.

The correct answer is: Bronchospasm

Explanation:

After a bronchoscopy and biopsy, the nurse should monitor for any signs of complications. Among the options provided, bronchospasm is the most urgent condition that requires immediate attention. Here's why:

Why bronchospasm is concerning:

Bronchospasm refers to the tightening of the muscles around the airways in the lungs, causing narrowing and difficulty breathing. This can occur as a reaction to the procedure and is a sign of airway obstruction. It can lead to respiratory distress and requires immediate intervention to open the airways, often with bronchodilators or other supportive care.

Why the other options are less urgent:

 Blood-streaked sputum:

A small amount of blood-streaked sputum is a common and expected finding after a bronchoscopy and biopsy. This is usually not a cause for concern unless it becomes profuse or persists, which would require further investigation.

 Dry cough:

A dry cough can occur after a bronchoscopy due to irritation or inflammation of the airways. It is typically a mild symptom and can be expected after such a procedure. If it is severe or associated with other symptoms, further evaluation is needed, but it is generally not an immediate concern.

Hematuria:

Hematuria (blood in the urine) is not typically related to a bronchoscopy. It is not an expected complication of the procedure and should be investigated. However, it is less likely to be directly linked to the bronchoscopy, and would not typically be considered an immediate emergency unless the client is also experiencing other systemic signs or has a history of urinary tract issues.

Summary:

Bronchospasm is the most serious and immediate concern following a bronchoscopy, as it can result in airway obstruction and difficulty breathing. The nurse should report this immediately to the physician for intervention. The other signs, such as blood-streaked sputum, dry cough, and hematuria, are less urgent and may be monitored unless they worsen or are associated with other symptoms.